Provider Demographics
NPI:1699063438
Name:DOMINGEZ, AUTUMN S (PHARM D, RPH)
Entity type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:S
Last Name:DOMINGEZ
Suffix:
Gender:F
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 W FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-3362
Mailing Address - Country:US
Mailing Address - Phone:336-294-0936
Mailing Address - Fax:336-834-9426
Practice Address - Street 1:1903 W FLORIDA ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-3362
Practice Address - Country:US
Practice Address - Phone:336-294-0936
Practice Address - Fax:336-834-9426
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18634183500000X
PARP441108183500000X
OHRPH03230864-2183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist